To the Editor:
We would like to thank Tana et al for their interest in our commentary.1 Their comments highlight the ongoing controversy surrounding the issue of management of patients with sarcoidosis during the coronavirus disease 2019 (COVID-19) pandemic. Large cohort studies addressing the issue of COVID-19 in patients with sarcoidosis are lacking. Thus, any guidance is based on expert opinion and extrapolation from other diseases. Obviously, such extrapolation is subject to errors, especially if these diseases are significantly different.
Although we agree with the assertion of Tana et al that immunomodulation differs in sarcoidosis vs other rheumatic diseases, it is unclear how great these differences are. More importantly, it is unclear if these differences have any relevance in terms of the risk and outcomes of infection from immunosuppression.
We also question the comments of Tana et al concerning the risks of corticosteroid therapy. It is true that dexamethasone has lowered the mortality rate of patients with severe COVID-19 infection who are receiving mechanical ventilation. However, it recently has also been shown that patients with rheumatic disease receiving ≥10 mg/d of prednisone had significantly higher rates of hospitalization from COVID-19 infection than those receiving <10 mg/d.2 These seemingly conflicting data suggest that it is too simplistic to state that an immunosuppressive drug is helpful or harmful in the face of COVID-19 infection without considering the timing of administration. It may be that immunosuppression initially allows COVID-19 to gain a foothold in the body and replicate rapidly. However, immunosuppression may mollify a subsequent cytokine storm and/or the development of an overly aggressive adaptive immune response.
The main premise of our article was that our recommendations are in keeping with the standard management of sarcoidosis to minimize immunosuppression of non-life-threatening disease and to monitor carefully for exacerbations. Although we are extrapolating from other diseases, the evidence is robust that corticosteroids pose a great risk of infection that appears higher than other immunosuppressive agents.3, 4, 5
The game is continuing to change. We acknowledge that our understanding of COVID-19 infection in sarcoidosis is currently very limited. As we await more evidence-based recommendations, we should remain vigilant to the risk of concomitant infections in patients with sarcoidosis. Our decision-making should take into consideration the rapidly changing landscape of the available COVID-19 therapeutics.
Footnotes
FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.
References
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